Justia Insurance Law Opinion SummariesArticles Posted in US Court of Appeals for the Seventh Circuit
Scanlon v. Life Insurance Co. of North America
Scanlon went on leave from his job as a Systems Administrator at McKesson. He requested accommodations to return to work; McKesson temporarily granted some, but not all, of them. Scanlon did not return to work but sought long-term disability insurance benefits under a McKesson group policy underwritten, insured, and administered by LINA. To meet the definition of “disabled” under the policy, an employee must be unable to perform the “material duties” of the employee’s regular occupation and earn 80% or more of the employee’s indexed earnings from working in the employee’s regular occupation. LINA denied Scanlon’s request and denied two administrative appeals after Scanlon supplied VA examination reports and letters and two residual functional capacity evaluations. LINA's medical examiners concluded that Scanlon was not entitled to benefitsIn a suit under ERISA, 29 U.S.C. 1132, the district court found that Scanlon, a veteran, suffered from myriad chronic orthopedic and sleep disorders that cause him pain and impact his daily life but found Scanlon ineligible for benefits, concluding Scanlon did not show that he cannot perform the material duties of his job. The Seventh Circuit vacated. The district court clearly erred when it failed to consider Scanlon’s inability to sit at his desk for eight hours a day as required by his occupation and his inability to perform the cognitive requirements of his job during regular work hours and in its treatment of certain medical records Scanlon provided. View "Scanlon v. Life Insurance Co. of North America" on Justia Law
Jadair International, Inc. v. American National Property & Casualty Co.
Schmutzler, the owner and president of Jadair, was a pilot with decades of experience. Schmutzler applied to American National for an insurance policy on its Cessna airplane in 2019. The application listed Schmutzler as the Cessna’s only authorized pilot; Schmutzler indicated that he was a licensed pilot with an FAA medical certificate. The application included “Minimum Pilot Requirements,” which stated that “there is no coverage in flight unless the aircraft is being operated by the pilot(s) designated on this document who has/have at least the certificates, ratings, and pilot experience indicated, and who … is/are properly qualified for the flight involved.” Schmutzler initialed this provision. The Cessna crashed in May 2020, killing Schmutzler, who was piloting the plane. The crash was caused by a mechanical failure.American National denied coverage because Schmutzler did not have a current and valid FAA medical certificate at the time of the accident; his previous certificate had expired. The district court granted American National summary and declaratory judgment. The Seventh Circuit affirmed. The policy unambiguously excludes coverage for any accident involving the Cessna where the pilot lacks a current FAA medical certificate. That requirement is an exclusion of coverage, not a failed condition of coverage. View "Jadair International, Inc. v. American National Property & Casualty Co." on Justia Law
Daniels v. United Healthcare Services, Inc.
The parents work for the School District. Through the District, they contracted for a self-funded health insurance plan. The District, not an outside insurer, bears sole financial responsibility for the payment of plan benefits. The District is also the plan administrator and named fiduciary but contracted with United HealthCare to serve as the third-party claims administrator, with the authority to deny or approve claims. The plan is a governmental plan, so the Employee Retirement Income Security Act does not apply, 29 U.S.C. 1003(b)(1). In 2017, daughter Megan—covered under her parents’ policy—suffered a mental health emergency. United approved Megan for 24 days of inpatient treatment and informed the family that it would not approve additional days. Her parents and Megan’s doctors disagreed and appealed internally within United. They elected to continue Megan’s inpatient treatment. They received a final denial of coverage notice, leaving most of Megan’s treatment expenses uncovered.The family sued United for breach of contract, bad faith, punitive damages, and interest under Wisconsin’s prompt pay statute but did not join the District as a defendant. The Seventh Circuit affirmed the dismissal of the suit. There was no contractual relationship between the plaintiffs and United. Wisconsin law does not permit them to sue United for tortious bad faith absent contractual privity. Wisconsin’s prompt pay statute applies only to insurers. View "Daniels v. United Healthcare Services, Inc." on Justia Law
Citizens Insurance Company of America v. Wynndalco Enterprises, LLC
After Wynndalco Enterprises, LLC was sued in two putative class actions for violating Illinois’ Biometric Information Privacy Act (“BIPA”), its business liability insurer, Citizens Insurance Company of America, filed an action seeking a declaration that it has no obligation under the terms of the insurance contract to indemnify Wynndalco for the BIPA violations or to supply Wynndalco with a defense. Citizens’ theory is that alleged violations of BIPA are expressly excluded from the policy coverage. Wynndalco counterclaimed, seeking a declaration to the contrary that Citizens is obligated to provide it with defense in both actions. The district court entered judgment on the pleadings for Wynndalco. The Seventh Circuit affirmed. The court explained that the narrowing construction that Citizens proposes to resolve that ambiguity is not supported by the language of the provision and does not resolve the ambiguity. Given what the district court described as the “intractable ambiguity” of the provision, the court held Citizens must defend Wynndalco in the two class actions. This duty extends to the common law claims asserted against Wynndalco in the other litigation, which, as Citizens itself argued, arise out of the same acts or omissions as the BIPA claim asserted in that suit. View "Citizens Insurance Company of America v. Wynndalco Enterprises, LLC" on Justia Law
Froedtert Health, Inc. v. Factory Mutual Insurance Co.
When the COVID-19 pandemic began, Froedtert Health faced overwhelming demand to provide lifesaving care, which required substantial investments in personal protective equipment, waste disposal mechanisms, and cleaning and sanitation supplies. Froedtert also modified its emergency room layout and adapted its facilities to provide COVID-19 testing and screening. Froedtert paused nonemergency, elective procedures. Froedtert spent $85 million on COVID-related costs and sought reimbursement under its all-risks policy with Mutual. The insurer determined that the COVID-related losses did not constitute a direct physical loss triggering the general coverage provision and $2 billion limit but paid Froedtert the maximum $1 million sub-limit under a separate, additional coverage provision for losses from communicable disease response.The Seventh Circuit affirmed the dismissal of Froedert’s subsequent lawsuit, noting the policy’s “dense detail.” The policy’s general coverage is limited by accompanying exclusions, including the broad exclusion for contamination losses. In a later section, the policy then affords certain specified Additional Coverages, including for communicable disease response costs. That additional coverage would not exist if it was not expressly delineated in the Additional Coverages section of the policy. View "Froedtert Health, Inc. v. Factory Mutual Insurance Co." on Justia Law
Astellas US Holding, Inc. v. Federal Insurance Co.
The 2005 Medicare amendment, launching prescription drug coverage, raised concerns that patient assistance plans could violate the Anti-Kickback Statute, 42 U.S.C. 1320a-7b, and the False Claims Act, 31 U.S.C. 3729, by effectively rewarding doctors and patients for choosing particular drugs. Astellas subsequently launched Xtandi, used to treat metastatic prostate cancer. Priced at $7,800 per month, Xtandi prescriptions were covered by Medicare up to about $6,000 per month. Astellas made contributions to two patient assistance plans. An Astellas marketing executive encouraged both plans to create special funds to provide co-pay assistance for only androgen receptor inhibitors like Xtandi and a few other medications. Astellas donated to the new funds but stopped after contributing about $27 million. Astellas continued contributing to broader prostate cancer funds.The Department of Justice began investigating; the Astellas marketing executive acknowledged that he had “hoped” and “expected” that the contributions would produce financial benefits for Astellas but that Astellas had made no efforts to calculate “a return on investment.” Astellas settled with the government for $100 million--$50 million for “restitution” to the government. Astellas sought indemnification from liability insurers, including Federal, which denied coverage.The Seventh Circuit affirmed summary judgment for Astellas. Under Illinois law, a party may not obtain liability insurance for genuine restitution it owes the victim of its intentional wrongdoing, but a party may obtain insurance for compensatory damages. In cases of ambiguity, Illinois favors settlements and freedom of contract. Federal wrote its insurance policy to try to extend coverage to the limit of what Illinois law would allow. Federal did not carry its burden of showing that the portion of the settlement payment for which Astellas seeks coverage is uninsurable restitution. View "Astellas US Holding, Inc. v. Federal Insurance Co." on Justia Law
Thirteen Investment Co., Inc. v. Foremost Insurance Co. Grand Rapids Michigan
Thirteen’s building suffered fire damages covered by Foremost’s policy. Thirteen retained Paramount as its public adjuster and general contractor for repairs. Paramount was “to be [Thirteen’s] agent and representative to assist in the preparation, presentation, negotiation, adjustment, and settlement” of the fire loss. Thirteen also “direct[ed] any insurance companies to include Paramount … on all payments on” the fire loss claim. Paramount negotiated the fire loss. Foremost delivered settlement checks to Paramount. The checks named Thirteen, its mortgagee, and Paramount as co-payees. Paramount endorsed the names of all co-payees, cashed the checks, and kept the proceeds. Paramount performed some repair work on the building before Thirteen sought a declaratory judgment that the insurer had breached its policy by not paying the claim.The Seventh Circuit affirmed summary judgment for Foremost. Paramount received and cashed the checks, discharging the insurer’s performance obligation under the policy. The court rejected Thirteen’s arguments that Foremost waived payment as an affirmative defense by failing to plead it in its answer; that, under controlling Illinois law, Foremost’s policy obligation was not discharged when it delivered the checks to Paramount, which cashed the checks; and that Foremost agreed to make claim payments to Thirteen in installments after Foremost had inspected repair work performed. View "Thirteen Investment Co., Inc. v. Foremost Insurance Co. Grand Rapids Michigan" on Justia Law
Meier v. Pacific Life Insurance Co.
Ron and Lorrie Meier investigated the purchase of a life insurance policy for Ron through Monarch Solutions. While they considered a policy offered by Lincoln, a nurse assessed Ron’s health and prepared a “Medical Supplement” and “Examiner’s Report.” Ron ultimately applied for a policy with Pacific. In June 2018, Pacific received a copy of the medical forms previously submitted to Lincoln. On July 26, Ron completed his Pacific application, referencing the Lincoln “medical examination.” Ron agreed to several terms, including a provision requiring him to update Pacific “in writing of any changes” to his health. Pacific accepted Ron’s application on July 30 and began the underwriting process. On August 6, Ron learned he had stage IV lung cancer and immediately began treatment. Ron and Lorrie orally disclosed Ron’s cancer diagnosis to their Monarch representative but did not inform Pacific. On September 6, Pacific delivered Ron's policy. A year later Ron died from lung cancer.After learning that Ron had failed to disclose his terminal cancer before the policy’s issuance date, Pacific rejected Lorrie’s claim. Pursuant to the Illinois Insurance Code, Pacific rescinded the policy and returned the premiums. The district court and Seventh Circuit ruled in favor of Pacific. Ron’s failure to inform Pacific of the diagnosis constituted a material misrepresentation allowing for the policy's rescission. View "Meier v. Pacific Life Insurance Co." on Justia Law
Stant USA Corp. v. Factory Mutual Insurance Co.
Stant is a manufacturer of products for automobile suppliers and automobile manufacturers, including vapor management systems, fuel delivery systems, and thermal management systems. The spread of COVID-19 in early 2020 and the ensuing government orders curtailing the operation of non-essential businesses resulted in the suspension or reduction in operations by Stant’s customers. Stant alleged that it suffered over $5.3 million in derivative financial losses.Stant sought to recover under an “all-risk” insurance policy sold by FM. Under the Contingent Time Element coverage in that policy, Stant argued it was entitled to coverage for lost income as a result of “physical loss or damage” at its customers’ properties. Stant claimed that the COVID-19 virus caused such “physical loss or damage” to its customers’ properties and that its resulting business interruption losses were covered under the policy. Stant sought a declaratory judgment that it was entitled to recover under a commercial insurance policy issued by FM. The Seventh Circuit affirmed the dismissal of the suit. The temporary loss of use or restrictions on use do not constitute “physical” damage or loss. View "Stant USA Corp. v. Factory Mutual Insurance Co." on Justia Law
Frankenmuth Mutual Insurance Co. v. Fun F/X II, Inc.
Fun's warehouse had a functional sprinkler system with a working water supply. In 2016, an inspector from Legacy found no problems. In 2017, the inspector found the system had no water pressure. South Bend Water Works could not explain the problem and had no record of shutting off the water. Two months later, Fun contacted the fire inspector, who did not know how to restore the water. Fun's owner again called the Water Works and was told there was no record of disconnection. He asked the operator to restore the water and “assumed that she was going to ... figure out what was going on.” Fun never heard from any Water Works personnel and did not check whether the water was restored. In 2018, another Legacy employee performed the inspection. Fun was not notified of any problems. A fire destroyed the warehouse in 2019. Fun claimed losses exceeding $7 million. The city apparently had capped the pipe supplying the sprinkler system in 2017 when the neighboring building was demolished. Fun's Frankenmuth insurance policy contained an exclusion for situations in which the insured knew of any suspension or impairment in any protective safeguard, including sprinkler systems, and failed to notify Frankenmuth.Frankenmuth obtained a declaratory judgment that it did not owe insurance coverage. The Seventh Circuit affirmed. Cao had knowledge in 2017 that the system had no water yet never reported that impairment nor determined that the problem was solved. View "Frankenmuth Mutual Insurance Co. v. Fun F/X II, Inc." on Justia Law